Medicine in India: Rough Road to Physician Accountability

Second in a series

NEW DELHI -- It had been half a year since Shishir Chand spread the ashes of his younger brother Vishal in the Ganges, India's holiest river. As his grief grew less intense, a lingering doubt came into focus.

Vishal had gone to the emergency room just 13 hours before he died from a heart attack, at age 33, and the doctor had sent him home with pills for heartburn and anxiety. It had never seemed quite right to Shishir. When he read a magazine article about medical negligence, in November 2011, it all came together in his mind.

He called Kunal Saha, MD, PhD, a U.S.-based physician whose wife had died on a vacation to India after doctors gave her an overdose of steroids. Saha's organization, People for Better Treatment India, had been helping victims of medical negligence since 2001.

The odds weren't great, though. It had taken Saha US$2 million and a decade of legal wrangling to reach a guilty verdict, and he was a doctor himself, connected to international experts.

"It is almost impossible for an ordinary Indian citizen to win a case of medical negligence today," Saha says. "The doctors have virtually no accountability."

Under the best of circumstances, Saha told MedPage Today/VICE, "There may be medical errors, errors in judgments, and a lot of medicine is in the gray area, so you can't blame the doctor." But, he added, "what is happening in India is not that. So many lives are being lost absolutely needlessly."

Research shows many doctors spend almost no time examining their patients, commonly miss diagnoses, and often prescribe useless or harmful medicines. (See first part of this series.)

Missing the warning signs

It's not clear how thoroughly Vishal's physician, Atul Chhabra, MBBS, probed his symptoms and background. Had he asked about family history -- it figures nowhere in the medical records -- he would have learned that Vishal's father suffered a fatal heart attack at 44.

Both Chhabra and his employer, Tata Main Hospital, as well as the latter's corporate parent, declined to comment on the case. But Vishal's experience may not be unusual. In a recent study by World Bank researchers, not one doctor asked about family history when fake patients at public health centers in Madhya Pradesh complained of heart attack symptoms.

Vishal's doctor probably suspected acid reflux. Meanwhile, he ignored Vishal's risk factors for heart disease; he didn't follow standard protocol, which includes keeping patients under observation and doing a series of EKGs, or electrocardiograms, for suspected heart attack; and he misread the one EKG he did order.

At some medical schools in India, students can graduate without learning to decipher the electric signature of a brewing heart attack. Gairik Ghosh, MS, MBBS, a 40-year-old orthopedic surgeon who received his degree from a prestigious medical school in Kolkata, had to teach himself to read electrocardiograms during a fellowship in the U.K.

"What we practiced and what we learned was pretty primitive," Ghosh recalls of his student days in Kolkata. "And I wouldn't just blame the teachers, because they were also taught in the same environment."

Corruption from top to bottom

Many experts worry the situation will only get worse, in part because medical education is under constant pressure from corruption.

Over the past two decades the number of private medical schools in India has soared. Along with tuition, many charge illegal admission fees that run as high as $150,000, a crippling expense that students must recoup from patients after they graduate.

Sting operations show some schools hire fake faculty and fake patients to pass inspections. In a recent case reported in the Times of India, "ghost" faculty were running private beauty salons and hair transplant clinics instead of teaching medicine.

Indeed, the government body tasked with regulating medical education, the Medical Council of India (MCI), was dissolved in 2010 following charges that its president accepted bribes for certifying a medical school that did not meet basic standards.

The council has been reconstituted, but the criticism persists. During his half-year stint as health minister last year, Harsh Vardhan, now minister of science and technology, called the MCI a "big source of corruption" and the country's drug regulator a "snake pit of vested interests."

The Internet forum Quality of Medical Education, which includes about 10,000 health professionals from across the country, frequently echoes this sentiment.

"Corruption is engulfing everything," Mukesh Yadav, MD, MBA, LLB, who founded the forum, told MedPage Today/VICE last year. "Obviously this is dangerous for patients."

A few months after the interview, Yadav was sacked from his post as professor and head of the department of forensic medicine and toxicology at Sharda University's School of Medical Sciences & Research in Delhi, in what he sees as punishment for his outspokenness against corruption.

Others worry less about medical schools and more about what happens later. While doctors are supposed to keep current through continuing medical education, most don't bother as nobody is keeping score, experts say.

Instead, many get medical updates only from pharmaceutical salespeople who offer gifts in exchange for prescriptions, as shown by a 2012 Reuters investigation.

Unnecessary tests and treatments also arise as a result of kickbacks for referrals, says David Berger, an Australia-based physician who volunteered recently at a small hospital in the Himalayas.

While healthcare fraud is a global problem, in India "you have basically institutionalized corruption," he told MedPage Today/VICE. "And to me that's the difference between India and the Western countries, where you can be corrupt, but it's your own choice."

More awareness, but no data

The general public may be waking up to the problems.

Local newspapers have been reporting on medical scandals -- from poor women having their uteruses wrongfully removed in a scam to bilk insurance programs, to a pediatric hospital where more than 3,800 infants died over four years, to a sterilization clinic using bicycle pumps to inflate women's abdomens prior to surgery.

And Saha's case has made headlines for years. In October 2013, it was featured in the New York Times after India's Supreme Court awarded Saha an unprecedented compensation of 60 million rupees, or nearly $1 million.

Some Indians fear seeing a doctor when they get sick. "I have relatives who never go to the doctor," says Aditya Jayanthi, 24, from Rajahmundry in Andhra Pradesh. "People are losing their faith in medical science because of the doctors' negligence."

Yet systematic data on medical errors and malpractice are lacking, because nobody tracks the problem, Times of India noted in a 2013 report entitled "Clean slate for doctors on medical negligence?"

'A full-time job'

Few patients have the resources to hold doctors accountable. Many wait years to hear back from medical boards, which in the end nearly always side with the doctor.

Because the Chands are relatively well off, Shishir could afford to leave his job at British Airways to prepare his brother's case.

"Getting a medical opinion, hiring a lawyer and then drafting a petition, it's a full-time job," he told MedPage Today/VICE. "It's very difficult."

People for Better Treatment helped, in part by connecting Shishir with two of the expert witnesses who testified on the family's behalf. Today the organization has offices in several Indian cities, staffed by volunteers who themselves have experience with malpractice.

A year and a half ago, Shishir became the group's Delhi coordinator. His complaint about Vishal's doctor was dismissed by the state medical board, which cited, among other things, lack of a hospital discharge ticket. After an appeal, the MCI issued a warning to Chhabra "to be more careful" in the future.

Meanwhile the court case continues. Shishir has also filed criminal charges against Tata Main and says there may be more coming. He has a list of five other patients who died there recently due to alleged negligence; in three cases, angry mobs stormed the premises.

To Ghosh, the surgeon who had to teach himself to read EKGs, the take-home message is clear.

"You don't have to be a super doctor, you have to be a safe doctor," he says. "A safe doctor follows certain protocols, so that you don't miss things."

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